29 Sep Unit 4 Case Studies
10669Identify a friend, peer, or family member you can interview to collect complete and comprehensive subjective and objective data sets, as though they were a new patient in your office for an annual wellness visit or establishing as a new patient to the practice.
Conduct an interview and physical exam.
Document your findings in a Word file. Structure the subjective and objective data sets in the format provided in your lecture materials.
RESOURCES:
Bickley, L.S. (2021). Overview: Physical examination and history taking. Bates’ guide to physical examination and history-taking, 13th ed. New York: Lippincott, Williams, & Wilkins. ISN-13:9781496398178
Chapter 16 – Cardiovascular System
Chapter 17 – Peripheral Vascular System
Chapter 19 – Abdomen
Unit 4 – Lecture
Comprehensive or Focused?
As the provider you must determine if your exam will be comprehensive or focused on a problem or body system.
A comprehensive assessment is usually recorded the first time you see the patient or during a well visit. It involves a very complete history of a patient’s history, their medical history, their surgical history, and their social history.
A focused assessment is a detailed examination of a specific body system or systems that relate to the presenting problem or chief complaint. It is often used during an acute complaint by the patient.
Unit 4 lecture img.JPG
Cardiovascular
Subjective
Here are some questions to ask when taking a patient’s cardiovascular history:
Chest pain: When did it start? Is this the first time you have experienced this chest pain? Have you had other types of chest pain? How frequently does your chest pain occur? How long does it last? Where is the pain located? Does it radiate?
Dyspnea or shortness of breath: Does this occur with or without activity? What type of activity? How does this compare to three or six months ago? What is the onset? Abrupt or gradual? Does position change affect the dyspnea? Does the shortness of breath awaken you at night? Do you associate the dyspnea with any chest discomfort?
Cough: Do you have a cough? If yes, how long have you had the cough? Is the cough associated with activity such as exercise, position change, talking, or anxiety? Does anything make the cough better such as rest, prescription, or over-the-counter (OTC) medications as well as home remedies?
Past cardiac history: Is there any history of hypertension, known coronary artery disease (CAD), hypercholesterolemia, heart murmur, congenital heart disease, transient ischemic attack (TIA) or cerebral vascular accident (CVA)? When was the patient’s last EKG, stress test, lipid panel, echo, etc. done?
Family history: Is there a family history of CAD? Include hypertension, diabetes, obesity, sudden death under age 65 years, and hyperlipidemia. Ask age of death for parents and siblings. For example, if all the males in the family died before age 65 due to sudden death or perhaps everyone had an acute myocardial infarct before age 70, document this as it would be pertinent to the patient’s history.
Cardiovascular Examination Summary
Objective Data
Neck:
Observe, palpate, and auscultate the carotid pulse.
Observe the venous pulse and estimate jugular venous pressure.
Precordium:
Inspect and palpate: apical impulse noting any lift, or thrill.
Auscultation:
Identify the areas.
Note rate and rhythm.
Note S1 and S2: Are there any variations?
Are there any extra heart sounds in systole and diastole?
Are there any murmurs in systole and diastole?
Begin with the diaphragm, repeat with the bell.
Auscultate the apex when the patient is in the left lateral position.
Auscultate the base with the patient in a sitting position.
After the examination it is important to document your findings.
The Abdomen
The abdomen can be described as the large oval hollow space that begins at the diaphragm and extends to the top of the pelvis. The posterior portion of the cavity is backed by the vertebral column and paravertebral muscles. The rib cage and abdominal muscles provide additional protection and support.
As you know, the abdominal wall is divided into four quadrants: right upper quadrant (RUQ), LUQ, right lower quadrant (RLQ), and left lower quadrant (LLQ). Fun information that you may not know: the terms epigastric, umbilical, hypogastric, or suprapubic are regional names that were used to describe the various areas of the abdomen when an older system of nine quadrants was used:
RUQ Contents
These include the liver, gallbladder, duodenum, head of the pancreas, right kidney and adrenal gland, hepatic flexure of the colon, and part of the ascending and transverse colon.
LUQ Contents
These include the stomach, spleen, left lobe of the liver, body of the pancreas, left kidney and adrenal gland, splenic flexure of the colon, and part of the transverse and descending colon.
RLQ Contents
These include the cecum, appendix, right ovary and tube, right ureter, and right spermatic cord.
LLQ Contents
These include the part of the descending colon, sigmoid colon, left ovary and tube, left ureter, and left spermatic cord.
Midline Contents
These include the aorta, the uterus if enlarged, and the bladder if distended.
Subjective Data
Appetite: Is there any change in your appetite? Is this a loss or increase in appetite? Have you experienced a weight change recently? Is this due to a specific diet or other problem?
Do you have abdominal pain? Where? Ask the patient to point to the pain. Does the pain move about or stay in one place? How does it start? How long does it last? When did you first notice the pain? Is the pain intermittent or constant? What does the pain feel like (cramping, wringing, burning, bloating, dull, aching, or stabbing)?
Nausea and vomiting: Any recent nausea and vomiting? What is the frequency and volume? Ask about color and odor, especially presence of blood. Any associated pain, diarrhea, constipation, fever, or chills?
Bowel habits: How often do you have a bowel movement? Do you consider this pattern normal? What is the color and consistency of the stool? Do you have any issues with diarrhea or constipation? How long have you had this problem? Have you experienced a recent change in your bowel habits?
Past abdominal history: Do you have any previous problems with ulcers, gallbladder, hepatitis or jaundice, appendicitis, colitis, or hernia? Describe your abdominal operations. Were there any post-operative problems from these surgeries? Any previous abdominal X-rays? What were the results?
Objective Data
Inspection:
The abdomen may be rounded, flat, protuberant, or scaphoid (sunken). Is the abdomen symmetric bilaterally?
The umbilicus should be midline, inverted, clear, or flesh colored, without bruising, inflammation, discoloration, or hernia.
The skin should be even in texture and color. The skin surface should be smooth to touch. Moles or nevi are usually brown papule or macules on the abdomen. Note any surgical scars, including position, length, and color.
Note any signs of infection or inflammation
Auscultation:
Listen before you feel. Palpation and percussion can increase bowel sound activity; therefore, you should always auscultate first.
Use the diaphragm of the stethoscope; place it lightly on the skin of the abdomen, starting at the RLQ. Bowel sounds are most likely to be present here at all times unless there is an underlying problem.
Listen for vascular sounds, such as a bruit. Use a firmer pressure over the aorta than you did with bowel sound auscultation.
Percussion:
Use percussion to identify and measure organs and any masses or fluid that might be present. Percuss all four quadrants with the expected finding to be tympany.
Start on the right sternal wall and percuss down until you hear the tympanic sound change to dullness. This is the top of the liver border and should be approximately at the fifth intercostal space.
Palpation:
Palpation can be used to locate and measure certain organs as well as screen for masses or tenderness.
Begin with light palpation across the four quadrants. Light palpation is to screen for tenderness and any masses or skin changes.
Deep palpation is conducted in a similar fashion to light palpation but with depressing the hand 5 to 8 cm.
NU610 Unit 4 Assignment – Case Studies Rubric
NU610 Unit 4 Assignment – Case Studies Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeSubjective Data
20 pts
Highly Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are adeptly documented (all 9 elements are correctly documented)
16 pts
Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are appropriately documented (at least 7 of the 9 elements are correctly documented)
12 pts
Marginally Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are satisfactorily documented (at least 5 of the 9 elements are correctly documented)
8 pts
Approaching Proficiency
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not satisfactorily documented (only 3 of the 9 elements are correctly documented)
4 pts
Not Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not satisfactorily documented (less than 3 of the 9 elements are correctly documented)
0 pts
Not Evident
An assignment submission is not located
20 pts
This criterion is linked to a Learning OutcomeObjective Data
20 pts
Highly Proficient
Elements of objective data are adeptly documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS
16 pts
Proficient
Elements of objective data are appropriately documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS
12 pts
Marginally Proficient
Elements of objective data are satisfactorily documented but do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS
8 pts
Approaching Proficiency
Elements of objective data are either not satisfactorily documented or do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS
4 pts
Not Proficient
Elements of objective data are not satisfactorily documented and do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS
0 pts
Not Evident
There are elements of objective data that are not provided in the assignment
20 pts
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